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Circulation. 2003;108:1146-1162
doi: 10.1161/01.CIR.0000073597.57414.A9
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(Circulation. 2003;108:1146.)
© 2003 American Heart Association, Inc.

ACC/AHA Guideline

ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography: Summary Article

A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography)

, Committee MembersMelvin D. Cheitlin, MD, MACC, Chair; William F. Armstrong, MD, FACC, FAHA; Gerard P. Aurigemma, MD, FACC, FAHA; George A. Beller, MD, FACC, FAHA; Fredrick Z. Bierman, MD, FACC; Jack L. Davis, MD, FACC; Pamela S. Douglas, MD, FACC, FAHA, FASE; David P. Faxon, MD, FACC, FAHA; Linda D. Gillam, MD, FACC, FAHA; Thomas R. Kimball, MD, FACC; William G. Kussmaul, MD, FACC; Alan S. Pearlman, MD, FACC, FAHA, FASE; John T. Philbrick, MD, FACP; Harry Rakowski, MD, FACC, FASE; Daniel M. Thys, MD, FACC, FAHA, Task Force Members; Elliott M. Antman, MD, FACC, FAHA, Chair; Sidney C. Smith, Jr, MD, FACC, FAHA, Vice-Chair; Joseph S. Alpert, MD, FACC, FAHA; Gabriel Gregoratos, MD, FACC, FAHA; Jeffrey L. Anderson, MD, FACC; Loren F. Hiratzka, MD, FACC, FAHA; David P. Faxon, MD, FACC, FAHA; Sharon Ann Hunt, MD, FACC, FAHA; Valentin Fuster, MD, PhD, FACC, FAHA; Alice K. Jacobs, MD, FACC, FAHA; Raymond J. Gibbons, MD, FACC, FAHA*,{dagger}; Richard O. Russell, MD, FACC, FAHA*


Key Words: ACC/AHA Guidelines • echocardiography • imaging

I. General Considerations and Scope

The previous guideline for the use of echocardiography was published in March 1997. Since that time, there have been significant advances in the technology of echocardiography and growth in its clinical use and in the scientific evidence leading to recommendations for its proper use.

Each section has been reviewed and updated in evidence tables, and where appropriate, changes have been made in recommendations. A new section on the use of intraoperative transesophageal echocardiography (TEE) is being added to update the guidelines published by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists. There are extensive revisions, especially of the sections on ischemic heart disease; congestive heart failure, cardiomyopathy, and assessment of left ventricular (LV) function; and screening and echocardiography in the critically ill. There are new tables of evidence and extensive revisions in the ischemic heart disease evidence tables.

Because of space limitations, only those sections and evidence tables with new recommendations will be printed in this summary article. Where there are minimal changes in a recommendation grouping, such as a change from Class IIa to Class I, only that change will be printed, not the entire set of recommendations. Advances for which the clinical applications are still being investigated, such as the use of myocardial contrast agents and three-dimensional echocardiography, will not be discussed.

The original recommendations of the 1997 guideline are based on a Medline search of the English literature from 1990 to May 1995. The original search yielded more than 3000 references, which the committee reviewed. For this guideline update, literature searching was conducted in Medline, EMBASE, Best Evidence, and the Cochrane Library for English-language meta-analyses and systematic reviews from 1995 through September 2001. Further searching was conducted for new clinical trials on the following topics: echocardiography in adult congenital heart disease, echocardiography for evaluation of chest pain in the emergency department, and intraoperative echocardiography. The new searches yielded more than 1000 references that were reviewed by the writing committee.

This document includes recommendations for the use of echocardiography in both adult and pediatric patients. The pediatric guidelines also include recommendations for fetal echocardiography, an increasingly important field. The guidelines include recommendations for the use of echocardiography in both specific cardiovascular disorders and the evaluation of patients with frequently observed cardiovascular symptoms and signs, common presenting complaints, or findings of dyspnea, chest discomfort, and cardiac murmur. In this way, the guidelines will provide assistance to physicians regarding the use of echocardiographic techniques in the evaluation of such common clinical problems.

The recommendations concerning the use of echocardiography follow the indication classification system (eg, Class I, II, and III) used in other American College of Cardiology/American Heart Association (ACC/AHA) guidelines:

Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.

IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.

IIb: Usefulness/efficacy is less well established by evidence/opinion.

Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.

Evaluation of the clinical utility of a diagnostic test such as echocardiography is far more difficult than assessment of the efficacy of a therapeutic intervention because the diagnostic test can never have the same direct impact on patient survival or recovery. Nevertheless, a series of hierarchical criteria are generally accepted as a scale by which to judge worth.1–3

Hierarchical Levels of Echocardiography Assessment

Because there are essentially no randomized trials assessing health outcomes for diagnostic tests, the committee has not ranked the available scientific evidence in an A, B, and C fashion (as in other ACC/AHA documents) but rather has compiled the evidence in tables. The evidence tables have been extensively revised and updated. All recommendations are thus based on either this evidence from observational studies or on the expert consensus of the committee.

The definition of echocardiography used in this document incorporates Doppler analysis, M-mode echocardiography, two-dimensional transthoracic echocardiography (TTE), and, when indicated, TEE. Intravascular ultrasound is not considered but is reviewed in the ACC/AHA Guidelines for Percutaneous Coronary Intervention1 (available at http://www. acc.org/clinical/guidelines/percutaneous/dirIndex.htm) and the Clinical Expert Consensus Document on intravascular ultrasound2 (available at http://www.acc.org/clinical/consensus/standards/standard12.htm). Echocardiography for evaluating the patient with cardiovascular disease for noncardiac surgery is considered in the ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery.3 The techniques of three-dimensional echocardiography are still in the developmental stages and are not considered here. New techniques that are still rapidly evolving and improvements that are purely technological in echo-Doppler instrumentation, such as color Doppler imaging and digital echocardiography, are not going to be separately discussed in the clinical recommendations addressed in this document. Tissue Doppler imaging, both pulsed and color, which detects low Doppler shift frequencies of high energy generated by the contracting myocardium and consequent wall motion, are proving very useful in evaluating systolic and diastolic myocardial function. However, these technological advances will also not be separately discussed in the clinical recommendations.4,5 Echocardiographic-contrast injections designed to assess myocardial perfusion to quantify myocardium at risk and perfusion beds also were not addressed.

These guidelines address recommendations about the frequency with which an echocardiographic study is repeated. If the frequency with which studies are repeated could be decreased without adversely affecting the quality of care, the economic savings realized would likely be significant. With a noninvasive diagnostic study and no known complications, the potential for repeating the study unnecessarily exists. It is easier to state when a repeat echocardiogram is not needed then when and how often it should be repeated, because no studies in the literature address this question. How often an echocardiogram should be done depends on the individual patient and must be left to the judgment of the physician until evidence-based data addressing this issue are available.

The ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography includes several significant changes in the recommendations and in the supporting narrative portion. In this summary, we list the updated recommendations, as well as commentary on some of the changes. All new or revised language in recommendations appears in boldface type. Only the references supporting the new recommendations are included in this article. The reader is referred to the full-text version of the guidelines posted on the American College of Cardiology (www.acc.org), American Heart Association (www.americanheart.org), and American Society for Echocardiography (www.asecho.org) World Wide Web sites for a more detailed exposition of the rationale for these changes.

Section II-B. Native Valvular Stenosis

Recommendations for Echocardiography in Valvular Stenosis
Comment: New references.6,7

Class IIb
2. Dobutamine echocardiography for the evaluation of patients with low-gradient aortic stenosis and ventricular dysfunction.

Section II-C. Native Valvular Regurgitation

Recommendations for Echocardiography in Native Valvular Regurgitation
Comment: Literature on valvular effects of anorectic drugs and references to echocardiographic predictors of prognosis after aortic and mitral valve surgery have been added.6–10

Class I
7. Assessment of the effects of medical therapy on the severity of regurgitation and ventricular compensation and function when it might change medical management.

8. Assessment of valvular morphology and regurgitation in patients with a history of anorectic drug use, or the use of any drug or agent known to be associated with valvular heart disease, who are symptomatic, have cardiac murmurs, or have a technically inadequate auscultatory examination.

Class III
2. Routine repetition of echocardiography in past users of anorectic drugs with normal studies or known trivial valvular abnormalities.

Section II-F. Infective Endocarditis: Native Valves

Recommendations for Echocardiography in Infective Endocarditis: Native Valves
Comment: The Duke Criteria for the diagnosis of infective endocarditis have been added, as well as the value of TEE in the setting of a negative transthoracic echocardiogram when there is high clinical suspicion or when a prosthetic valve is involved.11,12

Class I
6. If TTE is equivocal, TEE evaluation of staphylococcus bacteremia without a known source.

Class IIa
1. Evaluation of persistent nonstaphylococcus bacteremia without a known source.*

Class III
1. Evaluation of transient fever without evidence of bacteremia or new murmur.

Section II-G. Prosthetic Valves

Recommendations for Echocardiography in Valvular Heart Disease and Prosthetic Valves
Class I
3. Use of echocardiography (especially TEE) inguiding the performance of interventional techniques and surgery (eg, balloon valvotomy and valve repair) for valvular disease.

Section IV-A. Acute Ischemic Syndromes

Recommendations for Echocardiography in the Diagnosis of Acute Myocardial Ischemic Syndromes
Comment: Movement of a recommendation from Class IIa to Class I and minor wording change.

Recommendations for Echocardiography in Risk Assessment, Prognosis, and Assessment of Therapy in Acute Myocardial Ischemic Syndromes
Class I
4. Assessment of myocardial viability when required to define potential efficacy of revascularization.*

Class IIa
2. Moved to Class I (see above).

Class IIb
1. Assessment of late prognosis (greater than or equal to 2 years after acute myocardial infarction).

Section IV-B. Chronic Ischemic Heart Disease
Recommendations for Echocardiography in Diagnosis and Prognosis of Chronic Ischemic Heart Disease
Comment: There are new sections on stress echocardiography in the detection of coronary disease in the transplanted heart and stress echocardiography in the detection of coronary disease in women. There is one new Class I recommendation and three new Class IIa recommendations. Recommendations have been renumbered for clarity.

Class I
2. Exercise echocardiography for diagnosis of myocardial ischemia in selected patients (those for whom ECG assessment is less reliable because of digoxin use, LVH or with more than 1 mm ST depression at rest on the baseline ECG, those with pre-excitation [Wolff-Parkinson-White] syndrome, complete left bundle-branch block) with an intermediate pretest likelihood of CAD.

Class IIa

  1. Prognosis of myocardial ischemia in selected patients (those in whom ECG assessment is less reliable) with the following ECG abnormalities: pre-excitation (Wolff-Parkinson-White) syndrome, electronically paced ventricular rhythm, more than 1 mm of ST depression at rest, complete left bundle-branch block.*
  2. Detection of coronary arteriopathy in patients who have undergone cardiac transplantation.{dagger}
  3. Detection of myocardial ischemia in women with a low or intermediate pretest likelihood of CAD.*

Class IIb
1. Moved to Class IIa.

Recommendations for Echocardiography in Assessment of Interventions in Chronic Ischemic Heart Disease
One new Class IIa recommendation has been added.

Class IIa
1. Assessment of LV function in patients with previous myocardial infarction when needed to guide possible implantation of implantable cardioverter-defibrillator (ICD) in patients with known or suspected LV dysfunction.

Tables 1 through 6DownDownDownDownDown are new tables that relate to CAD.


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  		TABLE 1. Evaluation of Myocardial Viability With DSE in Patients With Chronic CAD and Impaired Systolic LV Function to Detect Hibernating Myocardium


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  		TABLE 2. Prognostic Value of Stress Echocardiography in Various Patient Populations*


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  		TABLE 3. Prognostic Value of Viable (Hibernating) Myocardium by LD-DSE and Influence of Revascularization


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  		TABLE 4. Diagnostic Accuracy of Exercise Echocardiography in Detecting Angiographically Proved CAD (Without Correction for Referral Bias)


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  		TABLE 5. Diagnostic Accuracy of Dobutamine Stress Echocardiography in Detecting Angiographically Proved CAD (Without Correction for Referral Bias)


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  		TABLE 6. Diagnostic Accuracy of Stress Echocardiography in Detecting Angiographically Proved CAD in Women (Generally Without Correction for Referral Bias)

Section V-B. Regional LV Function

Recommendations for Echocardiography in Patients With Dyspnea, Edema, or Cardiomyopathy
Class I
1. Dyspnea with clinical signs of heart disease.

Class IIb
1. Re-evaluation of patients with established cardiomyopathy when there is no change in clinical status but when the results might change management.

Class III
2. Routine re-evaluation in clinically stable patients in whom no change in management is contemplated and for whom the results would not change management.

Section IX. Pulmonary Disease

Recommendations for Echocardiography in Pulmonary and Pulmonary Vascular Disease
Comment: One recommendation was moved from Class I to Class IIa. Class IIa recommendations have been renumbered for clarity. Evidence was added concerning the diagnosis of severe pulmonary embolism by echocardiography.122

Class I
2. Moved to Class IIa (see below).

Class IIa
1. Pulmonary emboli and suspected clots in the right atrium or ventricle or main pulmonary artery branches.*

Section XII. Arrhythmias and Palpitations

Recommendations for Echocardiography in Patients With Arrhythmias and Palpitations
Comment: An additional Class IIb recommendation was made concerning the use of echocardiography in the Maze procedure.123–129

Class IIa
2. TEE or intracardiac ultrasound guidance of radiofrequency ablative procedures.

Class IIb
3. Postoperative evaluation of patients undergoing the Maze procedure to monitor atrial function.

Recommendations for Echocardiography Before Cardioversion
Class IIb
2. Patients with mitral valve disease or hypertrophic cardiomyopathy who have been on long-term anticoagulation at therapeutic levels before cardioversion unless there are other reasons for anticoagulation (eg, prior embolus or known thrombus on previous TEE).*

Class III
2. Patients who have been on long-term anticoagulation at therapeutic levels and who do not have mitral valve disease or hypertrophic cardiomyopathy before cardioversion unless there are other reasons for anticoagulation (eg, prior embolus or known thrombus on previous TEE).*

Section XIIa. Screening

Recommendations for Echocardiography to Screen for the Presence of Cardiovascular Disease
Comment: A section has been added on the molecular genetics work that has identified a familial basis for many forms of cardiomyopathy, including dilated congestive cardiomyopathy, hypertrophic cardiomyopathy, and right ventricular (RV) dysplasia. A possible genetic basis for these cardiomyopathies supports echocardiographic screening of first-degree relatives.130–138

Class I
5. First-degree relatives (parents, siblings, children) of patients with unexplained dilated cardiomyopathy in whom no etiology has been identified.

Class III
2. Routine screening echocardiogram for participation in competitive sports in patients with normal cardiovascular history, ECG, and examination.

Section XIII. Echocardiography in the Critically Ill

Recommendations for Echocardiography in the Critically Ill
Comment: This section has been revised extensively. A discussion has been added on the echocardiographic detection of pulmonary embolism and the usefulness of TEE versus TTE in the critically ill patient. A section on the value of echocardiography in blunt aortic trauma has also been added. The evidence tables have been extensively revised and updated.139–164

Class III
1. Suspected myocardial contusion in the hemodynamically stable patient with a normal ECG who has no abnormal cardiac/thoracic physical findings and/or lacks a mechanism of injury that suggests cardiovascular contusion.

Section XIV. Two-Dimensional Echocardiography in the Adult Patient With Congenital Heart Disease

Recommendations for Echocardiography in the Adult Patient With Congenital Heart Disease
Comment: A section has been added on the accuracy of echocardiography to allow surgery to proceed without catheterization in some congenital heart lesions. Echocardiography is useful in the performance of interventional therapeutic procedures.165–177

Class I

5. Patients with known congenital heart disease in whom it is important that pulmonary artery pressure be monitored (eg, patients with hemodynamically important, moderate, or large ventricular septal defects, atrial septal defects, single ventricle, or any of the above with an additional risk factor for pulmonary hypertension).
6. Periodic echocardiography in patients with repaired (or palliated) congenital heart disease with the following: change in clinical condition or clinical suspicion of residual defects, obstruction of conduits and baffles, or LV or RV function that must be monitored, or when there is a possibility of hemodynamic progression or a history of pulmonary hypertension.
8. Identification of site of origin and initial course of coronary arteries (TEE may be indicated in some patients).*

Section XV-E. Acquired Cardiovascular Disease in the Neonate

Recommendations for Neonatal Echocardiography
Comment: Only minor changes have been made in this section. Two new Class I recommendations and one Class III recommendation have been added.177–194 One recommenda-tion has moved from Class IIb to Class IIa. Class I recommendations have been renumbered for clarity.

Class I

12. Re-evaluation after initiation or termination of medical therapy for pulmonary artery hypertension.
13. Re-evaluation during initiation or withdrawal of extracorporeal cardiopulmonary support.

Class IIa
3. Presence of a syndrome associated with a high incidence of congenital heart disease for which there are no abnormal cardiac findings and no urgency of management decisions.

Class IIb
1. Moved to Class IIa (see above).

Class III
2. Acrocyanosis with normal upper- and lower-extremity pulsed oximetry oxygen saturations.

Section XV-F. Congenital Cardiovascular Disease in the Infant, Child, and Adolescent

Recommendations for Echocardiography in the Infant, Child, and Adolescent
Comment: There are two new Class I recommendations, which have been renumbered for clarity.6,195–200

Class I

5. Selection, placement, patency, and monitoring of endovascular devices, as well as identification of intracardiac or intravascular shunting before, during, and subsequent to interventional cardiac catheterization.
6. Immediate assessment after percutaneous interventional cardiac catheterization procedure.
10. Presence of a syndrome associated with cardiovascular disease and dominant inheritance or multiple affected family members (eg, Marfan syndrome or Ehlers-Danlos syndrome).

Deleted:

Phenotypic findings of Marfan syndrome or Ehlers-Danlos syndrome.

Presence of a syndrome associated with high incidence of congenital heart disease when there are no abnormal cardiac findings.

"Atypical," "nonvasodepressor" syncope without other causes.

Section XV-G. Arrhythmias/Conduction Disturbances

Recommendations for Echocardiography in Pediatric Patients With Arrhythmias/Conduction Disturbances
Comment: Echocardiography is discretionary after radiofrequency catheter ablation. Persistent ventricular dilatation after successful ablation or effective medical control of the heart rate may indicate an arrhythmogenic primary cardiomyopathy.201–203

Class IIa
2. Evidence of pre-excitation on ECG with symptoms.

Class IIb
3. Examination immediately after radiofrequency ablation.

Section XV-H. Acquired Cardiovascular Disease

Recommendations for Echocardiography in Pediatric Acquired Cardiovascular Disease
Comment: The leading cause of death after the first posttransplant year is transplant-related CAD. There is evidence that stress echocardiography identifies subclinical ischemia.204–213

Class I

3. Baseline and re-evaluation examinations of patients receiving cardiotoxic chemotherapeutic agents.
5. Patients with severe renal disease and/or systemic hypertension.

Class III
1. Routine screening echocardiogram for participation in competitive sports in patients with normal cardiovascular examination.

Section XV-I. Pediatric Acquired Cardiopulmonary Disease

Recommendations for Echocardiography in Pediatric Acquired Cardiopulmonary Disease
Comment: Echocardiography provides documentation of pulmonary artery hypertension and estimation of severity by the presence of RV dilation and/or hypertrophy, the presence of tricuspid or pulmonic valvular regurgitation, and Doppler estimation of RV systolic pressure.214,215

Class I

2. Re-evaluation after surgical intervention or initiation of oral and/or parenteral vasodilator therapy for pulmonary artery hypertension.
3. Re-evaluation during withdrawal of extracorporeal cardiopulmonary support.

Section XV-K. Transesophageal Echocardiography

Recommendations for TEE in Pediatric Patients
Comment: TEE has become particularly helpful in guiding placement of catheter-deployed devices used in closing atrial septal defects. It is essential in ensuring proper positioning of the device in the defect and assessing for residual shunts and abnormal device occlusion of venous inflow into the atria or encroachment on the atrioventricular valves. Likewise, placement of catheters for radiofrequency ablation of arrhythmogenic pathways can be facilitated by TEE when there are intracardiac abnormalities.216–222

Class I

2. Monitoring and guidance during cardiothoracic surgical procedures.
8. Patients with right atrial to pulmonary artery Fontan connection, for identification of atrial thrombus.

Class IIa
1. Patients with lateral tunnel Fontan palliation.

Section XVI. Intraoperative Echocardiography

Recommendations for Intraoperative Echocardiography
Comment: This section is new. In 1996, a task force of the American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists (ASA/SCA) published practice guidelines for perioperative TEE. The guidelines were evidence based and focused on the effectiveness of perioperative TEE in improving clinical outcomes. A literature search conducted at that time retrieved 1844 articles, of which 588 were considered relevant to the perioperative setting. A more recent literature search identified an additional 118 articles related to the intraoperative use of echocardiography. The current text makes reference only to the latter. However, the indications for intraoperative echocardiography that are provided in these guidelines are based on both the initial ASA/SCA guidelines and the newer information.223–260

For a detailed discussion of this topic, please see the full-text version of the guidelines posted on the ACC, AHA, and American Society of Echocardiography (ASE) World Wide Web sites.

Class I

  1. Evaluation of acute, persistent, and life-threatening hemodynamic disturbances in which ventricular function and its determinants are uncertain and have not responded to treatment.
  2. Surgical repair of valvular lesions, hypertrophic obstructive cardiomyopathy, and aortic dissection with possible aortic valve involvement.
  3. Evaluation of complex valve replacements requiring homografts or coronary reimplantation, such as the Ross procedure.
  4. Surgical repair of most congenital heart lesions that require cardiopulmonary bypass.
  5. Surgical intervention for endocarditis when preoperative testing was inadequate or extension to perivalvular tissue is suspected.
  6. Placement of intracardiac devices and monitoring of their position during port-access and other cardiac surgical interventions.
  7. Evaluation of pericardial window procedures in patients with posterior or loculated pericardial effusions.

Class IIa

  1. Surgical procedures in patients at increased risk of myocardial ischemia, myocardial infarction, or hemodynamic disturbances.
  2. Evaluation of valve replacement, aortic atheromatous disease, the Maze procedure, cardiac aneurysm repair, removal of cardiac tumors, intracardiac thrombectomy, and pulmonary embolectomy.
  3. Detection of air emboli during cardiotomy, heart transplant operations, and upright neurosurgical procedures.

Class IIb

  1. Evaluation of suspected cardiac trauma, repair of acute thoracic aortic dissection without valvular involvement, and anastomotic sites during heart and/or lung transplantation.
  2. Evaluation of regional myocardial function during and after off-pump coronary artery bypass graft procedures.
  3. Evaluation of pericardiectomy, pericardial effusions, and pericardial surgery.
  4. Evaluation of myocardial perfusion, coronary anatomy, or graft patency.
  5. Dobutamine stress testing to detect inducible demand ischemia or to predict functional changes after myocardial revascularization.
  6. Assessment of residual duct flow after interruption of patent ductus arteriosus.

Class III

1. Surgical repair of uncomplicated secundum atrial septal defect.

Footnotes

This document was approved by the American College of Cardiology Foundation Board of Trustees in May 2003, by the American Heart Association Science Advisory and Coordinating Committee in May 2003, and by the American Society of Echocardiography Board of Directors in May 2003.

The ACC/AHA Task Force on Practice Guidelines makes every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the writing panel. Specifically, all members of the writing panel are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. These statements are reviewed by the parent task force, reported orally to all members of the writing panel at the first meeting, and updated as changes occur. The relationship with industry information for the writing committee members is posted on the ACC and AHA World Wide Web sites with the full-length version of the update.

When citing this document, the American College of Cardiology, American Heart Association, and the American Society of Echocardiography request that the following citation format be used: Cheitlin MD, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, Davis JL, Douglas PS, Faxon DP, Gillam LD, Kimball TR, Kussmaul WG, Pearlman AS, Philbrick JT, Rakowski H, Thys DM. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines on the Clinical Application of Echocardiography). Circulation. 2003;108:1146–1162.

This document and the full text guideline are available on the World Wide Web sites of the American College of Cardiology (www.acc.org), the American Heart Association (www.americanheart.org), and the American Society of Echocardiography (www.asecho.org). To obtain a single copy of this summary article published in the September 3, 2003, issue of the Journal of the American College of Cardiology, the September 2, 2003, issue of Circulation, or the October, 2003, issue of the Journal of the American Society of Echocardiography, call 1-800-253-4636 or write to the American College of Cardiology Foundation, Resource Center, 9111 Old Georgetown Road, Bethesda, MD 20814-1699, and ask for reprint number 71-0263. To purchase additional reprints: up to 999 copies, call 1-800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 214-706-1466, fax 214-691-6342, or e-mail pubauth@heart.org.

*Former Task Force Member. Back

{dagger}Immediate Past Task Force Chair. Back

*TEE may frequently provide incremental value in addition to information obtained by TTE. The role of TEE in first-line examination awaits further study. Back

*Dobutamine stress echocardiography. Back

*Exercise or pharmacological stress echocardiogram. Back

{dagger}Dobutamine stress echocardiogram. Back

*TEE is indicated when TTE studies are not diagnostic. Back

*TEE only Back

*TEE may be necessary to image both coronary origins in adults. Back

References

  1. Smith SC Jr, Dove JT, Jacobs AK, et al. ACC/AHA guidelines of percutaneous coronary interventions (revision of the 1993 PTCA guidelines: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1993 Guidelines for Percutaneous Transluminal Coronary Angioplasty). J Am Coll Cardiol. 2001; 37: 2215–2239.[Free Full Text]
  2. Mintz GS, Nissen SE, Anderson WD, et al. American College of Cardiology clinical expert consensus document on standards for acquisition, measurement and reporting of intravascular ultrasound studies (IVUS): a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2001; 37: 1478–1492.[Free Full Text]
  3. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery update: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Available at: http://www.acc.org/clinical/guidelines/perio/update/periupdate_index.htm. Accessed June 12, 2002.
  4. Sutherland GR, Stewart MJ, Groundstroem KW, et al. Color Doppler myocardial imaging: a new technique for the assessment of myocardial function. J Am Soc Echocardiogr. 1994; 7: 441–458.[Medline] [Order article via Infotrieve]
  5. Isaaz K. Pulsed Doppler tissue imaging. Am J Cardiol. 1998; 81: 663.Letter.
  6. Bonow RO, Carabello BA, Cheitlin MD. American College of Cardiology/American Heart Association practice guidelines for the management of patients with valvular heart disease. J Am Coll Cardiol. 1998; 32: 1486–1588.[Free Full Text]
  7. Jick H. Heart valve disorders and appetite-suppressant drugs. JAMA. 2000; 283: 1738–1740.Editorial.[Free Full Text]
  8. Corti R, Binggeli C, Turina M, et al. Predictors of long-term survival after valve replacement for chronic aortic regurgitation: is M-mode echocardiography sufficient? Eur Heart J. 2001; 22: 866–873.[Abstract/Free Full Text]
  9. Gardin JM, Schumacher D, Constantine G, et al. Valvular abnormalities and cardiovascular status following exposure to dexfenfluramine or phentermine/fenfluramine. JAMA. 2000; 283: 1703–1709.[Abstract/Free Full Text]
  10. Flemming MA, Oral H, Rothman ED, et al. Echocardiographic markers for mitral valve surgery to preserve left ventricular performance in mitral regurgitation. Am Heart J. 2000; 140: 476–482.[CrossRef][Medline] [Order article via Infotrieve]
  11. Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med. 1994; 96: 200–209.[CrossRef][Medline] [Order article via Infotrieve]
  12. Rosen AB, Fowler VG Jr, Corey GR, et al. Cost-effectiveness of transesophageal echocardiography to determine the duration of therapy for intravascular catheter-associated Staphylococcus aureus bacteremia. Ann Intern Med. 1999; 130: 810–820.[Abstract/Free Full Text]
  13. Marzullo P, Parodi O, Reisenhofer B, et al. Value of rest thallium-201/technetium-99m sestamibi scans and dobutamine echocardiography for detecting myocardial viability. Am J Cardiol. 1993; 71: 166–172.[CrossRef][Medline] [Order article via Infotrieve]
  14. Cigarroa CG, deFilippi CR, Brickner ME, et al. Dobutamine stress echocardiography identifies hibernating myocardium and predicts recovery of left ventricular function after coronary revascularization. Circulation. 1993; 88: 430–436.[Abstract/Free Full Text]
  15. Alfieri O, La Canna G, Giubbini R, et al. Recovery of myocardial function: the ultimate target of coronary revascularization. Eur J Cardiothorac Surg. 1993; 7: 325–330.[Abstract]
  16. La Canna G, Alfieri O, Giubbini R, et al. Echocardiography during infusion of dobutamine for identification of reversibly dysfunction in patients with chronic coronary artery disease. J Am Coll Cardiol. 1994; 23: 617–626.[Abstract]
  17. Charney R, Schwinger ME, Chun J, et al. Dobutamine echocardiography and resting-redistribution thallium-201 scintigraphy predicts recovery of hibernating myocardium after coronary revascularization. Am Heart J. 1994; 128: 864–869.[CrossRef][Medline] [Order article via Infotrieve]
  18. Afridi I, Kleiman NS, Raizner AE, et al. Dobutamine echocardiography in myocardial hibernation: optimal dose and accuracy in predicting recovery of ventricular function after coronary angioplasty. Circulation. 1995; 91: 663–670.[Abstract/Free Full Text]
  19. Perrone-Filardi P, Pace L, Prastaro M, et al. Dobutamine echocardiography predicts improvement of hypoperfused dysfunctional myocardium after revascularization in patients with coronary artery disease. Circulation. 1995; 91: 2556–2565.[Abstract/Free Full Text]
  20. Senior R, Glenville B, Basu S, et al. Dobutamine echocardiography and thallium-201 imaging predict functional improvement after revascularisation in severe ischaemic left ventricular dysfunction. Br Heart J. 1995; 74: 358–364.[Abstract/Free Full Text]
  21. Haque T, Furukawa T, Takahashi M, et al. Identification of hibernating myocardium by dobutamine stress echocardiography: comparison with thallium-201 reinjection imaging. Am Heart J. 1995; 130: 553–563.[CrossRef][Medline] [Order article via Infotrieve]
  22. Arnese M, Cornel JH, Salustri A, et al. Prediction of improvement of regional left ventricular function after surgical revascularization: a comparison of low-dose dobutamine echocardiography with 201Tl single-photon emission computed tomography. Circulation. 1995; 91: 2748–2752.[Abstract/Free Full Text]
  23. deFilippi CR, Willett DL, Irani WN, et al. Comparison of myocardial contrast echocardiography and low-dose dobutamine stress echocardiography in predicting recovery of left ventricular function after coronary revascularization in chronic ischemic heart disease. Circulation. 1995; 92: 2863–2868.[Abstract/Free Full Text]
  24. Iliceto S, Galiuto L, Marchese A, et al. Analysis of microvascular integrity, contractile reserve, and myocardial viability after acute myocardial infarction by dobutamine echocardiography and myocardial contrast echocardiography. Am J Cardiol. 1996; 77: 441–445.[CrossRef][Medline] [Order article via Infotrieve]
  25. Varga A, Ostojic M, Djordjevic-Dikic A, et al. Infra-low dose dipyridamole test: a novel dose regimen for selective assessment of myocardial viability by vasodilator stress echocardiography. Eur Heart J. 1996; 17: 629–634.[Abstract/Free Full Text]
  26. Baer FM, Voth E, Deutsch HJ, et al. Predictive value of low dose dobutamine transesophageal echocardiography and fluorine-18 fluorodeoxyglucose positron emission tomography for recovery of regional left ventricular function after successful revascularization. J Am Coll Cardiol. 1996; 28: 60–69.[Abstract]
  27. Vanoverschelde JL, D’Hondt AM, Marwick T, et al. Head-to-head comparison of exercise-redistribution-reinjection thallium single-photon emission computed tomography and low dose dobutamine echocardiography for prediction of reversibility of chronic left ventricular ischemic dysfunction. J Am Coll Cardiol. 1996; 28: 432–442.[Abstract]
  28. Gerber BL, Vanoverschelde JL, Bol A, et al. Myocardial blood flow, glucose uptake, and recruitment of inotropic reserve in chronic left ventricular ischemic dysfunction: implications for the pathophysiology of chronic myocardial hibernation. Circulation. 1996; 94: 651–659.[Abstract/Free Full Text]
  29. Bax JJ, Cornel JH, Visser FC, et al. Prediction of recovery of myocardial dysfunction after revascularization: comparison of fluorine-18 fluorodeoxyglucose/thallium-201 SPECT, thallium-201 stress-reinjection SPECT and dobutamine echocardiography. J Am Coll Cardiol. 1996; 28: 558–564.[Abstract]
  30. Perrone-Filardi P, Pace L, Prastaro M, et al. Assessment of myocardial viability in patients with chronic coronary artery disease: rest-4-hour-24-hour 201Tl tomography versus dobutamine echocardiography. Circulation. 1996; 94: 2712–2719.[Abstract/Free Full Text]
  31. Qureshi U, Nagueh SF, Afridi I, et al. Dobutamine echocardiography and quantitative rest-redistribution 201Tl tomography in myocardial hibernation: relation of contractile reserve to 201Tl uptake and comparative prediction of recovery of function. Circulation. 1997; 95: 626–635.[Abstract/Free Full Text]
  32. Nagueh SF, Vaduganathan P, Ali N, et al. Identification of hibernating myocardium: comparative accuracy of myocardial contrast echocardiography, rest-redistribution thallium-201 tomography and dobutamine echocardiography. J Am Coll Cardiol. 1997; 29: 985–993.[Abstract]
  33. Furukawa T, Haque T, Takahashi M, et al. An assessment of dobutamine echocardiography and end-diastolic wall thickness for predicting post-revascularization functional recovery in patients with chronic coronary artery disease. Eur Heart J. 1997; 18: 798–806.[Abstract/Free Full Text]
  34. Cornel JH, Bax JJ, Fioretti PM, et al. Prediction of improvement of ventricular function after revascularization: 18F-fluorodeoxyglucose single-photon emission computed tomography vs low-dose dobutamine echocardiography. Eur Heart J. 1997; 18: 941–948.[Abstract/Free Full Text]
  35. Picano E, Severi S, Michelassi C, et al. Prognostic importance of dipyridamole-echocardiography test in coronary artery disease. Circulation. 1989; 80: 450–457.[Abstract/Free Full Text]
  36. Sawada SG, Ryan T, Conley MJ, et al. Prognostic value of a normal exercise echocardiogram. Am Heart J. 1990; 120: 49–55.[CrossRef][Medline] [Order article via Infotrieve]
  37. Mazeika PK, Nadazdin A, Oakley CM. Prognostic value of dobutamine echocardiography in patients with high pretest likelihood of coronary artery disease. Am J Cardiol. 1993; 71: 33–39.[CrossRef][Medline] [Order article via Infotrieve]
  38. Krivokapich J, Child JS, Gerber RS, et al. Prognostic usefulness of positive or negative exercise stress echocardiography for predicting coronary events in ensuing twelve months. Am J Cardiol. 1993; 71: 646–651.[CrossRef][Medline] [Order article via Infotrieve]
  39. Afridi I, Quinones MA, Zoghbi WA, et al. Dobutamine stress echocardiography: sensitivity, specificity, and predictive value for future cardiac events. Am Heart J. 1994; 127: 1510–1515.[CrossRef][Medline] [Order article via Infotrieve]
  40. Poldermans D, Fioretti PM, Boersma E, et al. Dobutamine-atropine stress echocardiography and clinical data for predicting late cardiac events in patients with suspected coronary artery disease. Am J Med. 1994; 97: 119–125.[CrossRef][Medline] [Order article via Infotrieve]
  41. Coletta C, Galati A, Greco G, et al. Prognostic value of high dose dipyridamole echocardiography in patients with chronic coronary artery disease and preserved left ventricular function. J Am Coll Cardiol. 1995; 26: 887–894.[Abstract]
  42. Kamaran M, Teague SM, Finkelhor RS, et al. Prognostic value of dobutamine stress echocardiography in patients referred because of suspected coronary artery disease. Am J Cardiol. 1995; 76: 887–891.[CrossRef][Medline] [Order article via Infotrieve]
  43. Williams MJ, Odabashian J, Lauer MS, et al. Prognostic value of dobutamine echocardiography in patients with left ventricular dysfunction. J Am Coll Cardiol. 1996; 27: 132–139.[Abstract]
  44. Anthopoulos LP, Bonou MS, Kardaras FG, et al. Stress echocardiography in elderly patients with coronary artery disease: applicability, safety and prognostic value of dobutamine and adenosine echocardiography in elderly patients. J Am Coll Cardiol. 1996; 28: 52–59.[Abstract]
  45. Marcovitz PA, Shayna V, Horn RA, et al. Value of dobutamine stress echocardiography in determining the prognosis of patients with known or suspected coronary artery disease. Am J Cardiol. 1996; 78: 404–408.[CrossRef][Medline] [Order article via Infotrieve]
  46. Heupler S, Mehta R, Lobo A, et al. Prognostic implications of exercise echocardiography in women with known or suspected coronary artery disease. J Am Coll Cardiol. 1997; 30: 414–420.[Abstract]
  47. McCully RB, Roger VL, Mahoney DW, et al. Outcome after normal exercise echocardiography and predictors of subsequent cardiac events: follow-up of 1,325 patients. J Am Coll Cardiol. 1998; 31: 144–149.[Abstract/Free Full Text]
  48. Chuah SC, Pellikka PA, Roger VL, et al. Role of dobutamine stress echocardiography in predicting outcome in 860 patients with known or suspected coronary artery disease. Circulation. 1998; 97: 1474–1480.[Abstract/Free Full Text]
  49. Cortigiani L, Dodi C, Paolini EA, et al. Prognostic value of pharmacological stress echocardiography in women with chest pain and unknown coronary artery disease. J Am Coll Cardiol. 1998; 32: 1975–1981.[Abstract/Free Full Text]
  50. Davar JI, Brull DJ, Bulugahipitiya S, et al. Prognostic value of negative dobutamine stress echo in women with intermediate probability of coronary artery disease. Am J Cardiol. 1999; 83: 100–102,A8.[CrossRef][Medline] [Order article via Infotrieve]
  51. Ciliberto GR, Massa D, Mangiavacchi M, et al. High-dose dipyridamole echocardiography test in coronary artery disease after heart transplantation. Eur Heart J. 1993; 14: 48–52.[Abstract/Free Full Text]
  52. Lewis JF, Selman SB, Murphy JD, et al. Dobutamine echocardiography for prediction of ischemic events in heart transplant recipients. J Heart Lung Transplant. 1997; 16: 390–393.[Medline] [Order article via Infotrieve]
  53. Meluzin J, Cerny J, Frelich M, et al, on behalf of the Investigators of this Multicenter Study. Prognostic value of the amount of dysfunctional but viable myocardium in revascularized patients with coronary artery disease and left ventricular dysfunction. J Am Coll Cardiol. 1998; 32: 912–920.[Abstract/Free Full Text]
  54. Afridi I, Grayburn PA, Panza JA, et al. Myocardial viability during dobutamine echocardiography predicts survival in patients with coronary artery disease and severe left ventricular systolic dysfunction. J Am Coll Cardiol. 1998; 32: 921–926.[Abstract/Free Full Text]
  55. Limacher MC, Quinones MA, Poliner LR, et al. Detection of coronary artery disease with exercise two-dimensional echocardiography: description of a clinically applicable method and comparison with radionuclide ventriculography. Circulation. 1983; 67: 1211–1218.[Abstract/Free Full Text]
  56. Armstrong WF, O’Donnell J, Dillon JC, et al. Complementary value of two-dimensional exercise echocardiography to routine treadmill exercise testing. Ann Intern Med. 1986; 105: 829–835.[Medline] [Order article via Infotrieve]
  57. Armstrong WF, O’Donnell J, Ryan T, et al. Effect of prior myocardial infarction and extent and location of coronary disease on accuracy of exercise echocardiography. J Am Coll Cardiol. 1987; 10: 531–538.[Abstract]
  58. Ryan T, Vasey CG, Presti CF, et al. Exercise echocardiography: detection of coronary artery disease in patients with normal left ventricular wall motion at rest. J Am Coll Cardiol. 1988; 11: 993–999.[Abstract]
  59. Labovitz AJ, Lewen M, Kern MJ, et al. The effects of successful PTCA on left ventricular function: assessment by exercise echocardiography. Am Heart J. 1989; 117: 1003–1008.[CrossRef][Medline] [Order article via Infotrieve]
  60. Sawada SG, Ryan T, Fineberg NS, et al. Exercise echocardiographic detection of coronary artery disease in women. J Am Coll Cardiol. 1989; 14: 1440–1447.[Abstract]
  61. Sheikh KH, Bengtson JR, Helmy S, et al. Relation of quantitative coronary lesion measurements to the development of exercise-induced ischemia assessed by exercise echocardiography. J Am Coll Cardiol. 1990; 15: 1043–1051.[Abstract]
  62. Pozzoli MM, Fioretti PM, Salustri A, et al. Exercise echocardiography and technetium-99m MIBI single-photon emission computed tomography in the detection of coronary artery disease. Am J Cardiol. 1991; 67: 350–355.[CrossRef][Medline] [Order article via Infotrieve]
  63. Crouse LJ, Harbrecht JJ, Vacek JL, et al. Exercise echocardiography as a screening test for coronary artery disease and correlation with coronary arteriography. Am J Cardiol. 1991; 67: 1213–1218.[CrossRef][Medline] [Order article via Infotrieve]
  64. Galanti G, Sciagra R, Comeglio M, et al. Diagnostic accuracy of peak exercise echocardiography in coronary artery disease: comparison with thallium-201 myocardial scintigraphy. Am Heart J. 1991; 122: 1609–1616.[CrossRef][Medline] [Order article via Infotrieve]
  65. Marwick TH, Nemec JJ, Pashkow FJ, et al. Accuracy and limitations of exercise echocardiography in a routine clinical setting. J Am Coll Cardiol. 1992; 19: 74–81.[Abstract]
  66. Quinones MA, Verani MS, Haichin RM, et al. Exercise echocardiography versus 201Tl single-photon emission computed tomography in evaluation of coronary artery disease: analysis of 292 patients. Circulation. 1992; 85: 1026–1031.[Abstract/Free Full Text]
  67. Salustri A, Pozzoli MM, Hermans W, et al. Relationship between exercise echocardiography and perfusion single-photon emission computed tomography in patients with single-vessel coronary artery disease. Am Heart J. 1992; 124: 75–83.[CrossRef][Medline] [Order article via Infotrieve]
  68. Amanullah AM, Lindvall K, Bevegard S. Exercise echocardiography after stabilization of unstable angina: correlation with exercise thallium-201 single photon emission computed tomography. Clin Cardiol. 1992; 15: 585–589.[Medline] [Order article via Infotrieve]
  69. Hecht HS, DeBord L, Shaw R, et al. Digital supine bicycle stress echocardiography: a new technique for evaluating coronary artery disease. J Am Coll Cardiol. 1993; 21: 950–956.[Abstract]
  70. Ryan T, Segar DS, Sawada SG, et al. Detection of coronary artery disease with upright bicycle exercise echocardiography. J Am Soc Echocardiogr. 1993; 6: 186–197.[Medline] [Order article via Infotrieve]
  71. Mertes H, Erbel R, Nixdorff U, et al. Exercise echocardiography for the evaluation of patients after nonsurgical coronary artery revascularization. J Am Coll Cardiol. 1993; 21: 1087–1093.[Abstract]
  72. Hoffmann R, Lethen H, Kleinhans E, et al. Comparative evaluation of bicycle and dobutamine stress echocardiography with perfusion scintigraphy and bicycle electrocardiogram for identification of coronary artery disease. Am J Cardiol. 1993; 72: 555–559.[CrossRef][Medline] [Order article via Infotrieve]
  73. Cohen JL, Ottenweller JE, George AK, et al. Comparison of dobutamine and exercise echocardiography for detecting coronary artery disease. Am J Cardiol. 1993; 72: 1226–1231.[CrossRef][Medline] [Order article via Infotrieve]
  74. Marwick TH, D’Hondt AM, Mairesse GH, et al. Comparative ability of dobutamine and exercise stress in inducing myocardial ischaemia in active patients [published erratum appears in Br Heart J. 1994;72:590]. Br Heart J. 1994; 72: 31–38.[Abstract/Free Full Text]
  75. Roger VL, Pellikka PA, Oh JK, et al. Identification of multivessel coronary artery disease by exercise echocardiography. J Am Coll Cardiol. 1994; 24: 109–114.[Abstract]
  76. Marangelli V, Iliceto S, Piccinni G, et al. Detection of coronary artery disease by digital stress echocardiography: comparison of exercise, transesophageal atrial pacing and dipyridamole echocardiography. J Am Coll Cardiol. 1994; 24: 117–124.[Abstract]
  77. Beleslin BD, Ostojic M, Stepanovic J, et al. Stress echocardiography in the detection of myocardial ischemia: head-to-head comparison of exercise, dobutamine, and dipyridamole tests. Circulation. 1994; 90: 1168–1176.[Abstract/Free Full Text]
  78. Williams MJ, Marwick TH, O’Gorman D, et al. Comparison of exercise echocardiography with an exercise score to diagnose coronary artery disease in women. Am J Cardiol. 1994; 74: 435–438.[CrossRef][Medline] [Order article via Infotrieve]
  79. Roger VL, Pellikka PA, Oh JK, et al. Stress echocardiography, part I: exercise echocardiography: techniques, implementation, clinical applications, and correlations. Mayo Clin Proc. 1995; 70: 5–15.[Medline] [Order article via Infotrieve]
  80. Dagianti A, Penco M, Agati L, et al. Stress echocardiography: comparison of exercise, dipyridamole and dobutamine in detecting and predicting the extent of coronary artery disease [published erratum appears in J Am Coll Cardiol. 1995;26:1114]. J Am Coll Cardiol. 1995; 26: 18–25.[Abstract]
  81. Marwick TH, Anderson T, Williams MJ, et al. Exercise echocardiography is an accurate and cost-efficient technique for detection of coronary artery disease in women. J Am Coll Cardiol. 1995; 26: 335–341.[Abstract]
  82. Bjornstad K, Aakhus S, Hatle L. Comparison of digital dipyridamole stress echocardiography and upright bicycle stress echocardiography for identification of coronary artery stenosis. Cardiology. 1995; 86: 514–520.[Medline] [Order article via Infotrieve]
  83. Marwick TH, Torelli J, Harjai K, et al. Influence of left ventricular hypertrophy on detection of coronary artery disease using exercise echocardiography. J Am Coll Cardiol. 1995; 26: 1180–1186.[Abstract]
  84. Tawa CB, Baker WB, Kleiman NS, et al. Comparison of adenosine echocardiography, with and without isometric handgrip, to exercise echocardiography in the detection of ischemia in patients with coronary artery disease. J Am Soc Echocardiogr. 1996; 9: 33–43.[CrossRef][Medline] [Order article via Infotrieve]
  85. Luotolahti M, Saraste M, Hartiala J. Exercise echocardiography in the diagnosis of coronary artery disease. Ann Med. 1996; 28: 73–77.[Medline] [Order article via Infotrieve]
  86. Tian J, Zhang G, Wang X, et al. Exercise echocardiography: feasibility and value for detection of coronary artery disease. Chin Med J (Engl). 1996; 109: 381–384.[Medline] [Order article via Infotrieve]
  87. Roger VL, Pellikka PA, Bell MR, et al. Sex and test verification bias: impact on the diagnostic value of exercise echocardiography. Circulation. 1997; 95: 405–410.[Abstract/Free Full Text]
  88. Berthe C, Pierard LA, Hiernaux M, et al. Predicting the extent and location of coronary artery disease in acute myocardial infarction by echocardiography during dobutamine infusion. Am J Cardiol. 1986; 58: 1167–1172.[CrossRef][Medline] [Order article via Infotrieve]
  89. Sawada SG, Segar DS, Ryan T, et al. Echocardiographic detection of coronary artery disease during dobutamine infusion. Circulation. 1991; 83: 1605–1614.[Abstract/Free Full Text]
  90. Previtali M, Lanzarini L, Ferrario M, et al. Dobutamine versus dipyridamole echocardiography in coronary artery disease. Circulation. 1991; 83: III-27–III-31.[Medline] [Order article via Infotrieve]
  91. Cohen JL, Greene TO, Ottenweller J, et al. Dobutamine digital echocardiography for detecting coronary artery disease. Am J Cardiol. 1991; 67: 1311–1318.[CrossRef][Medline] [Order article via Infotrieve]
  92. Martin TW, Seaworth JF, Johns JP, et al. Comparison of adenosine, dipyridamole, and dobutamine in stress echocardiography. Ann Intern Med. 1992; 116: 190–196.[Medline] [Order article via Infotrieve]
  93. McNeill AJ, Fioretti PM, el Said SM, et al. Dobutamine stress echocardiography before and after coronary angioplasty. Am J Cardiol. 1992; 69: 740–745.[CrossRef][Medline] [Order article via Infotrieve]
  94. Segar DS, Brown SE, Sawada SG, et al. Dobutamine stress echocardiography: correlation with coronary lesion severity as determined by quantitative angiography. J Am Coll Cardiol. 1992; 19: 1197–1202.[Abstract]
  95. Mazeika PK, Nadazdin A, Oakley CM. Dobutamine stress echocardiography for detection and assessment of coronary artery disease. J Am Coll Cardiol. 1992; 19: 1203–1211.[Abstract]
  96. Marcovitz PA, Armstrong WF. Accuracy of dobutamine stress echocardiography in detecting coronary artery disease. Am J Cardiol. 1992; 69: 1269–1273.[CrossRef][Medline] [Order article via Infotrieve]
  97. McNeill AJ, Fioretti PM, el Said EM, et al. Enhanced s